Provider Demographics
NPI:1114493814
Name:DENNISTON, KIEFER D
Entity Type:Individual
Prefix:
First Name:KIEFER
Middle Name:D
Last Name:DENNISTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 N ALTAMONT ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-5265
Mailing Address - Country:US
Mailing Address - Phone:509-608-6174
Mailing Address - Fax:
Practice Address - Street 1:165 E HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2629
Practice Address - Country:US
Practice Address - Phone:509-684-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60882171101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor